Healthcare Provider Details

I. General information

NPI: 1740592054
Provider Name (Legal Business Name): BERNALILLO COUNTY YOUTH SERVICES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 2ND ST NW
ALBUQUERQUE NM
87107-4009
US

IV. Provider business mailing address

PO BOX 25945
ALBUQUERQUE NM
87125-0945
US

V. Phone/Fax

Practice location:
  • Phone: 505-468-7236
  • Fax:
Mailing address:
  • Phone: 505-468-7236
  • Fax: 505-462-9917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number97PA03
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9628
License Number StateNM

VIII. Authorized Official

Name: MR. THOMAS E. SWISSTACK
Title or Position: DIRECTOR
Credential:
Phone: 505-468-7122